Evaluation Of Nutritional Risk And Nutritional Support During Perioperative Period In Infants With Congenital Heart Disease

Malnutrition is very common in infants with congenital heart disease (CHD) especially in patients with heart failure and pulmonary hypertension, which have influence on clinical prognosis and the growth and development of children in particular. How to carry out the nutrition risk screening and nutrition support for this kind of children has become the hot spot of domestic and foreign research. With the improvement of surgical technique and postoperative intensive care level, age of surgery for congenital heart disease become more younger than before, the majority of children can be treatment in the infant stage, the sooner the time of surgery, the more conducive to children in the growth and development of children, but surgery to younger children will face more kinds of risks including nutritional risk and more challenge for nutritional support Due to the lagging development of pediatric clinical nutrition, the nutritional risk assessment and support in the early stage of congenital heart disease is still in the initial stage, especially in infants with congenital heart disease. Both surgeons and critical care physicians lack awareness of the nutritional status of patients with congenital heart disease, especially in infants and young children, and the negative effects of malnutrition or excess on the children, but not routine nutritional risk screening, nutritional status assessment and regular monitoring, the implementation of the nutritional support and treatment are not regular monitoring, the implementation of the nutritional support and treatment are not regular, many treatment means only rely on experience and lack of evidence-based clinical verification data. Patients with congenital heart disease are often faced with insufficient feeding or feeding during the preoperative period, resulting in adverse outcome such as infection, and the related complications and higher death rate. In this study, we evaluated the nutritional risk and common clinical factors, combined with professional nutritional support team to carry out early enteral nutrition support (Enteral Nutrition, EN), and to analyze the differences and possible strategies of C-response protein, nutrition related parameters, such as Screen Tool for Risk On Nutritional status and Growth.kids (STRONG.KIDS), Cardiac intensive care unit (CICU), et al., and to carry out the study on the resting energy metabolism in patients with congenital heart disease. Comparison of the difference among different disease types and different operation mode of the children with the detection of resting energy, clear the rest of the congenital heart disease and the energy of the existing formula, compared with the existing formula for the accuracy of the energy supply to provide a theoretical basis. This study also water to provide scientific basis and new ideas for the development of standardized preoperative nutrition support and improving effect of short-term and long-term prognosis to children with congenital heart disease.Section One Nutritional risk screening in hospitalized patients with congenital heart diseaseObjcettiveThe purpose of study is to analysis the relationship between the characteristics of preoperative nutritional risk in patients with heart disease and its clinical outcome through nutritional risk screening survey.MethodsThe nutritional risk assessment and questionnaire survey were designed based on the screening tool STRONGKIDS to screen the nutritional risk of 780 children admitted between August 2010 and April 2013. The incidence of nutritional risk in hospitalized children with congenital heart disease and its relationship with age, pulmonary hypertension and malnutrition, as well as the effect of nutritional risk on clinical outcome were analyzed.Results780 children with CHD (522 cases VSD[ventricular septal defect, VSD],133 cases ASD[atrial septal defect, ASD],70 cases TOF[tetralogy of Fallot, TOF] and 55 cases PDA[Patent ductus arteriosus, PDA]) were recruited.33.3% of the patients have moderate and high degree nutritional risks, meantime,the prevalence of nutritional risks is vary among different age children(0-1 year:49.2%; 1-3 years: 26.2% and≥ 3 years:7.6%). among patients with moderate and high nutritional risks,95%(247/260) and 91%(237/260) of those have pulmonary hypertension and malnutrition, respectively. The incidence of infection among severe and moderate nutritional risk was 46% and 32%, respectively. Hospital stays and intensive care time of patients with severe nutritional risk were higher than patients with moderate nutritional risk.ConclusionChildren with congenital heart disease have moderate and high nutritional risk, and high nutritional risk in children with congenital heart disease will lead to bad clinical outcome. Nutritional risk screening should become the first step for the perioperative management of nutrition.Section Two Early enteral nutrition support improve the clinical outcome of congenital heart disease Chapter IEarly enteral nutritional support on clinical outcomes of congenital heart disease ObjectiveTo investigate the effect of early enteral nutrition support on postoperative gastrointestinal function, energy supply and the improvement of clinical prognosis in patients with congenital heart disease, and to study the feasibility of early enteral nutrition support.Methods50 cases of ventricular septal defect aged six months to one year old were treated with early enteral nutrition support, According to the early enteral nutrition support program, withdraw of mechanical ventilation was withdraw after the surgery. giving enteral nutrition 12-24h after surgery, the first time, the number of feeding interruption, the time of feeding, the time of ventilator, and the related complications were recorded.Resultscomparison of the preoperative data between two groups,:preoperative C-reactive protein (CRP) were 8, preoperative early enteral nutrition group visual retinaldehyde protein(RBP), prealbumin(Pre-ALB) and control group compared the difference between the two groups had no significant difference (P=0.68); after 3 days of C-reactive protein in the early enteral nutrition group was significantly lower than that of control group, discharge forward-looking retinal protein and prealbumin early enteral nutrition group were significantly higher than those of control group (P <0.05).In the early EN group and control group, the change of body weight (0.13+0.17-0.06 vs 0.16 kg) and the first stool time (33.02 1.64 vs 56.50 h 1.37) were significantly different (P< 0.05), the difference of the mechanical ventilation time and intensive care unit (ICU) time in the two groups was not statistically significant (P=0.53). Enteral nutrition support was 68 times in the early enteral nutrition group and 65 in the control group.ConclusionsEarly EN can help gastrointestinal function、enhance body immunity and resistance to infection and increased energy supply. It also did not add gastrointestinal complications. ICU time and ventilation time have no difference in two groups.50 cases with VSD use early enteral nutrition support cases,another 50 VSD cases datas were find in 3 years ago.chapter ⅡCauses of interruptions in postoperative enteral nutrition in children withcongenital heart diseaseObjectivePerioperative nutrition support has become a hot topic in the clinical management of CHD. Postoperative enteral nutrition (EN) offers many benefits, such as, protection of the intestinal mucosa, reduced risk of infection and low clinical costs. Interruptions in EN frequently influence nutritional support and clinical outcomes. We, therefore, aimed todetermine the causes ofinterruptions in postoperative EN in CHD patients and discuss clinical countermeasures.MethodsWe analyzed the data of 360 CHD patients to determine the causes of interruptions in postoperativeEN and develop possibleclinical strategies to prevent such interruptions.ResultsOf the 360 patients (ages,1 month to 6 years),198patientshad at least one EN interruption. The total number of interruptions was 498 (average,2.52 interruptions/patient). Non-gastrointestinalfactors (airway management,fluid overload,invasive procedure, etc.)accounted for 67.8%(338/498) of all interruptions, while gastrointestinalfactors (vomiting, gastrointestinal bleeding, etc.) accounted for 32.2%(160/498) of all interruptions. The total number of interruptions and the number of interruptions due to gastrointestinal factors were significantly higher in younger patients (ages,1 month to 1 year) than in older patients (ages,1 year to 6 years).ConclusionsNon-gastrointestinalfactors were the main causes of interruptions in postoperative EN in CHD patients. Younger patients had a greater number of interruptions and a greater number of interruptions caused by gastrointestinal factors. Gastrointestinalfactors can be reduced by tube feeding and gastrointestinal motilitydrugs.Section ThreePostoperative energy metabolism rule of Congenital heart diseaseObjcettiveThe energy metabolism of the patients with congenital heart disease was monitored by resting energy meter, and the energy metabolism and the influencing factors were defined.Methods50 patients with congenital heart disease admitted between August 2013 and August were recruited in this study 2014,8 hours after operation, the resting energy metabolism (REE), and REE/Pred(Predictive value) (%) 90-110_ were compared with Harris-Benedict (>110).<90 was used in the metabolic state. The relationship between the different metabolic states, in vitro circulation and muscle relaxation was analyzed.Use Ultima CCM Express to detect 8 hours after surgeon patient’s energy metabolism.This result compare with H-B (Harris-Benedict) calculated and divide all patients into hypometabolic、normometabolic、hypermetabolismstate. Statistic CPB time(Cardiopulmonary bypass)、ACC time (Aortic occlusion) and muscle relaxation drug use and to find the relationship with metabolic state.ResultsIn 50 cases of children, ranging in age from 6 months to 1 year old, male 22, female 28 cases, which in the off-pump group (minimally invasive closure of ventricular septal defect (VSD) in 10 cases,20 cases of cardiopulmonary bypass surgery for ventricular septal defect, tetralogy of Fallot in 20 patients with postoperative were given support for dopamine 3-10μg/kg in line with recycling, and some of them muscle relaxants,24-96 hours of mechanical ventilation time, intensive care time 64-120 hours. Of the 50 children, only 13 (26%) of the REE/Pred (%) 90-110_ were normal metabolic state.10 cases of off-pump group were all high metabolic state; 20 cases of non cyanotic after cardiopulmonary bypass in 12 cases of high metabolism and 8 cases of normal metabolic state, normal metabolism in 2 cases with muscle relaxants. And cyanotic after cardiopulmonary bypass in 8 cases of high metabolism, 5 cases normal metabolism and 7 cases low metabolic state.7 cases with low metabolism, the time of cardiopulmonary bypass, aortic occlusion, ventilator assisted time and ICU time were significantly longer than normal metabolism and high metabolism. Muscle relaxation drugs were used in all the patients with low metabolism.ConclusionsThe energy metabolism in patients with congenital heart disease after operation was significantly different, compared with resting energy metabolism, the Harris-Benedict formula was less accurate.